Original Article
Proximity of Arthroscopic Ankle Stabilization Procedures to Surrounding Structures: An Anatomic Study

https://doi.org/10.1016/j.arthro.2013.02.011Get rights and content

Purpose

To examine the anatomy of the lateral ankle after arthroscopic repair of the lateral ligament complex (anterior talofibular ligament [ATFL] and calcaneofibular ligament [CFL]) with regard to structures at risk.

Methods

Ten lower extremity cadaveric specimens were obtained and were screened for gross anatomic defects and pre-existing ankle laxity. The ATFL and CFL were sectioned from the fibula by an open technique. Standard anterolateral and anteromedial arthroscopy portals were made. An additional portal was created 2 cm distal to the anterolateral portal. The articular surface of the fibula was identified, and the ATFL and CFL were freed from the superficial and deeper tissues. Suture anchors were placed in the fibula at the ATFL and CFL origins and were used to repair the origin of the lateral collateral structures. The distance from the suture knot to several local anatomic structures was measured. Measurements were taken by 2 separate observers, and the results were averaged.

Results

Several anatomic structures lie in close proximity to the ATFL and CFL sutures. The ATFL sutures entrapped 9 of 55 structures, and no anatomic structures were inadvertently entrapped by the CFL sutures. The proximity of the peroneus tertius and the extensor tendons to the ATFL makes them at highest risk of entrapment, but the proximity of the intermediate branch of the superficial peroneal nerve (when present) is a risk with significant morbidity.

Conclusions

Our results indicate that the peroneus tertius and extensor tendons have the highest risk for entrapment and show the smallest mean distances from the anchor knot to the identified structure. Careful attention to these structures, as well as the superficial peroneal nerve, is mandatory to prevent entrapment of tendons and nerves when one is attempting arthroscopic lateral ankle ligament reconstruction.

Clinical Relevance

Defining the anatomic location and proximity of the intervening structures adjacent to the lateral ligament complex of the ankle may help clarify the anatomic safe zone through which arthroscopic repair of the lateral ligament complex can be safely performed.

Section snippets

Methods

Ten lower extremity cadaveric specimens from the level of the knee joint distal to the toes were obtained from 10 fresh cadavers (mean age, 40 ± 12 years) and were screened for gross anatomic defects and pre-existing ankle laxity. A stress test performed on each of the specimens confirmed that less than 10° of laxity was present before testing. The other 10 lower extremity cadaveric specimens from these cadavers were used for a separate study. A 5- to 7-cm curved incision was made over the

Results

Our results indicate that several anatomic structures lie in close proximity to the ATFL and CFL sutures. The ATFL sutures entrapped significantly more structures compared with sutures in the CFL: 9 of 55 structures compared with 0 of 55 structures (P = .0017). The ATFL sutures entrapped 2 different structures in 3 of the specimens, so a total of 6 of 10 specimens had entrapped structures. The ATFL sutures entrapped the extensor tendons (2 specimens), peroneus tertius (5 specimens),

Discussion

Prevention of lateral ankle instability is paramount, given the risk of late sequelae, including degenerative arthritis.13 Many techniques have been described, including anatomic,6, 14, 15 nonanatomic,4, 16, 17, 18, 19, 20 and graft reconstruction–type procedures.16, 21 There are several advantages of an anatomic repair, such as restoring normal ankle anatomy and joint kinematics while maintaining motion of the ankle and subtalar joints.6, 14, 22 Relying on poor-quality tissue for lateral

Conclusions

In the model studied, the sutures at the location of the ATFL entrapped significantly more structures than the sutures from the CFL anchor. Our results indicate that the peroneus tertius and extensor tendons have the highest risk for entrapment and show the smallest mean distances from the anchor knot to the identified structure. Careful attention to these structures, as well as the SPN, is mandatory to prevent entrapment of tendons and nerves when one is attempting arthroscopic lateral ankle

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    The authors report that they have no conflicts of interest in the authorship and publication of this article.

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